DEPARTMENT OF CHILDREN AND FAMILIES

Division of Family and Economic Security

Wisconsin Works (W-2) Formal Assessment Agreement

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].

Applicant / Participant Name / Personal Identification Number / RFA / Case Number

You could benefit from a formal assessment. A formal assessment is an appointment with a doctor, psychologist, counselor, vocational rehabilitation specialist, or other professional.

What type of formal Assessment do you need?

The formal assessment will gather information about your (W-2 agency will check all that apply):

Expected short-term medical condition or injury:

Pregnancy

Expected long-term medical condition:

Learning needs

Emotional or mental health

Alcohol or other substance abuse

Vocational rehabilitation

Other – Specify:

How will a Formal Assessment help you?

The formal assessment results will help you and your Financial and Employment Planner (FEP) make informed decisions about:

Your W-2 placement;

Your employment goals and the activities that will help you reach your goals;

Your ability to do training and education activities; and

Any special services and work site accommodations that you may need.

What is an Accommodation?

Accommodations are changes that make it easier for you to do your W-2 activities. Here are some examples of accommodations and why the accommodation is needed:

Giving you extra help understanding directions if you have a learning disability;

Changing your start time if you are taking medicine for a health problem that makes you sleepy in the morning;

Giving you a quiet workspace to reduce noise if you have a mental disability; or

Assigning you to a dust-free work area if you have asthma or are allergic to dust.

It is important for you to know that:

  1. You do not have to pay for any formal assessments. The cost of formal assessments will be paid for by your health insurance (such as BadgerCare), the W-2 agency, Division of Vocational Rehabilitation or by another program.
  1. Your information will be kept private. Information gathered from a formal assessment is confidential. It will only be used by the W-2 agency to help you in the W-2 program. If you move and apply for W-2 with a different W-2 agency, your formal assessment information will be shared with the new W-2 agency.
  1. Your W-2 agency will help you complete a formal assessment. You have the right to ask the W-2 agency for reasonable modifications or accommodations to help you complete a formal assessment. Tell your FEP if you need help completing a formal assessment.
  1. You can choose not to do a formal assessment. If you decide not to complete the formal assessment, you will not be penalized in any way. You will not be sanctioned or found ineligible for W-2 based on your decision to decline a formal assessment.
  1. If you decline a formal assessment, your FEP will work with you to make all W-2 placement decisions and activity assignments based on the information that is available. However,

Your FEP may not have enough information to determine if you have a disability or other barrier to participation in the W-2 program; and

Your FEP may not be able to provide services or worksite accommodations that could help you.

Applicant / Participant must check one of the boxes below indicating whether s/he has agreed or declined to have a formal assessment.

I agree to have a formal assessment. If I move and apply for W-2 with a different. W-2 agency, my formal assessment information will be shared with the new W-2 agency.

I decline to complete a formal assessment at this time.

Applicant/Participant Signature / Date Signed
W-2 Agency Representative Signature / Date Signed

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DCF-F-2565-E (N. 08/2010)